A claims payer (also known as an insurance company) may deny claims based on individual line-item claim data. This denial generally happens for several

A claims payer (also known as an insurance company) may deny claims based on individual line-item claim data. This denial generally happens for several reasons: intake errors on the front end during patient registration, mismatch with diagnosis and procedure coding documented by the health system, or technology issues. If the claim is denied, health systems are required to resubmit the claim, either by correcting the error(s) on the claim or submitting an appeal if they disagree with the denial. Insurance companies may require a resubmission of all original documents. This process is part of the revenue-cycle workflow of a healthcare organization.

This discussion will help you assess the internal and external revenue-cycle workflows and their impact on strategic planning and financial management. It will also enable you to evaluate how the revenue cycle is impacted by insurance plan requirements and regulations and identify front-end, middle, and back-end revenue-cycle processes within operational workflows.

This discussion will help you to prepare for sections 3 (Healthcare Reimbursement), 4 (Revenue-Cycle Process), and 5C (Technology and System Impacts) of the course project.

Imagine you work with a healthcare organization, and you are helping the internal audit team analyze quarterly financial performance. The audit team found several claim denials in the outpatient surgery center and has asked you for a better understanding of the situation.

In your initial post, include the following details:

  • Explain how technology and human error may contribute to a denial by the insurance company.
  • Identify at least one internal process breakdown each from the front-end, middle, and back-end workflows that could lead to a claim denial.

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

Section A Input Data

Section A Input Data EduCredit is the education loan division of a bank. It is considering a batch of applications for student loans repayable in one year. EduCredit charges each loan applicants an annual interest rate that depends on the band of their credit scores (A is the highest) Loan

Homework  Channels and Metrics Note:  At the start of your DQ post,

Homework  Channels and Metrics Note:  At the start of your DQ post, remind us of the company and product/service you have chosen for your marketing campaign. Choose one social media channel and one traditional channel that you plan to use in your marketing campaign. For each channel, answer the following

BUSI46S15 Competitive Strategies & Organisational Fitness

BUSI46S15 Competitive Strategies & Organisational Fitness Postgraduate Programmes 2023/24 SUMMATIVE ASSIGNMENT – BUSI46S15 Competitive Strategies and Organizational Fitness Select an organization, identify its competitive environment (that is, the population it is a member of) [5 marks] Analyse (qualitatively) the ecological and institutional conditions in the population. [10 marks] Provide a